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92-2698
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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92-2698
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Last modified
3/31/2020 10:04:45 PM
Creation date
12/4/2017 6:24:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
92-2698
STREET_NUMBER
800
Direction
W
STREET_NAME
CHURCH
STREET_TYPE
ST
City
STOCKTON
SITE_LOCATION
800 W CHURCH ST
RECEIVED_DATE
07/30/1992
P_LOCATION
NEWARK SIERRA
Supplemental fields
FilePath
\MIGRATIONS\C\CHURCH\800\92-2698.PDF
QuestysFileName
92-2698
QuestysRecordID
1691122
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUINLOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> = PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED ' <br /> + (Complete in Triplicate) - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.-This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.,1862 for well/pump and the R4ies and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City 1574, Lot Size' PM <br /> Owner's NameIVQLVLLIiC `Q.lr/��i( Address 121 J Phone <br /> Contractorft/411 � /~ Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFfCATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications <br />_ ❑ Public ��❑l�O/t��h""pr 17 Delta Depth of Grout Seal Type of Grout <br /> E: Irrigation _�approx. Depth Eastern ?urface Seal Installed by f <br /> Repair Work Done ❑ Type of Pump H.P. f/.[l�� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 <br /> Depth Filler Material (Below 50'1 �- <br /> ..TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t <br /> available within 200 feet.) <br /> Installation will server Residence— Commercial— Other <br /> Number of living units: Number of bedrooms -�- <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity '*No`Compartments <br /> PKG. TREATMENT PLT. ❑ RMethod of'Disposal <br /> Distance to nearest: Well Foundation Property Line. -, <br /> LEACHING LINE ❑ No. & Length of lines Total length/-size ` I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ "-Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line , <br /> DISPOSAL PONDS ❑ <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in'accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." ry <br /> The applicant m t call fired inspections. Complete drawing onpqrse side. I <br /> SignedAir-111 '-7-,,3P0Title: :Date: <br /> ' � <br /> A� <br /> / <br /> FOR DEPARTMENT USE ONLY l a <br /> Application Accepted by Date p -;2- Area <br /> Pit or Grout Inspection by Date Final Inspection by Date/ y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-823-7104— -❑ Tracy-'835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED OK 0 +' RECEIVED BY DATE 'PERMIT'NO.' <br /> + EH 13-241REV.r/e5} R TV` (/'✓ vo <br /> EH 14-26 // / <br />
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